Health conditions in the occupied Palestinianterritory, including east Jerusalem, and in theoccupied Syrian Golan

Report by the Secretariat

1. In 2011, the Sixty-fourth World Health Assembly adopted resolution WHA64.4, which requested the Director-General, inter alia, to report on its implementation to the Sixty-fifth World Health Assembly. In addition, the resolution requested the Director-General, inter alia, to submit a fact-finding report on the health and economic situation in the occupied Palestinian territory, including east Jerusalem, and in the occupied Syrian Golan.

2. The current population for the occupied Palestinian territory is 4 168 858 (2 580 167 in the West Bank (northern governorates) and 1 588 691 in the Gaza Strip (southern governorates)).1Real growth in gross domestic product, previously projected to reach 10% in 2011, is expected to be revised to 5% for the same year. Growth had been steadily increasing in 2009–2010, but driven primarily by donor assistance. As such, the economy was especially vulnerable to the lower aid flows in the first half of 2011. The shortfall in external financial support has also contributed to the current fiscal crisis facing the Palestinian Authority.2

3. Infant mortality rates in the occupied Palestinian territory have decreased slowly over the last two decades but a gap in rates is emerging between rates in the West Bank and the Gaza Strip. The infant mortality rate declined from 25.5 per 1000 live births in 2000 to 20.6 per 1000 live births in 2010 (18.8 in the West Bank and 23.0 in the Gaza Strip). Similarly, the under-five mortality rate declined from 28.7 per 1000 live births in 2000 to 25.1 per 1000 live births in 2010 but with a wide gap between regions (22.1 in the West Bank and 29.2 in the Gaza Strip). Two thirds of infant deaths occurred within the neonatal period, mostly during the first days of life. Conditions originating in the perinatal period are the leading cause of under-five mortality in the West Bank, at 50.8%.3Maternal mortality was reported at 32 per 100 000 live births in 2010 in the West Bank and 29 per 100 000 live births in the Gaza Strip – a ratio comparable to neighbouring Arab countries,4but evidence suggests pregnancy-linked deaths are likely to be underreported.

4. Anaemia and micronutrient deficiencies are further areas of concern. It is estimated that 50% of infants and young children under two years of age in the West Bank and the Gaza Strip suffer from iron deficiency anaemia which is associated with inappropriate feeding practices for infants and young children, as well as limited access to, or compliance with, micronutrient supplementation. Anaemia levels in pregnant women are routinely measured and monitored. For malnutrition in children under five years, stunting (chronic malnutrition) is not improving and may be deteriorating. A high prevalence of anaemia is revealed among women visiting antenatal services (39.1% of pregnant women in the Gaza Strip and 15.4% in the West Bank).

KEY AREAS OF WHO SUPPORT TO THE PALESTINIAN MINISTRY OF HEALTH

5. In 2011, WHO continued to support the Palestinian Ministry of Health in assessing the health information system based on the global assessment tool of the Health Metrics Network. WHO and the Ministry of Health are currently finalizing the health information system strategy based on the assessment in order to establish a comprehensive and reliable system of national health information.

6. Since January 2009, WHO has been leading the Health and Nutrition Cluster of the occupied Palestinian territory, which provides a joint coordination and partnership forum for 50 partners from United Nations organizations, nongovernmental organizations, and the private and public sectors. The cluster partners provide essential health and nutrition services to the vulnerable communities of the West Bank and the Gaza Strip and build local capacities for rapid response to new emergencies. The cluster developed a contingency plan, carried out assessment and mapping of health and nutrition needs in the West Bank and the Gaza Strip and developed its response plan. The response plan seeks to improve access to essential health services, strengthen protection of civilians and health staff and build local emergency response capacities.

7. The cluster also conducted a participatory evaluation of its performance and identified objectives for 2012. WHO led the process of defining emergency health sector standards and helped in standardizing humanitarian health and nutrition responses.

8. In collaboration with the Ministry of Health, WHO carried out an assessment of the health needs of the population living in “Area C”, focusing on the extent to which primary care services are adequate and accessible. The purpose of the assessment is to identify priority investments and interventions in the health sector which will help to address the current shortcomings in the provision of related services and to improve such services to the population.

9. WHO has provided support to fill some of the gaps in the supply of pharmaceuticals and continued to help in coordinating the import of medical supplies donated to the Gaza Strip. The Organization also provided urgently needed technical assistance, medical equipment and spare parts to maintain, repair and improve existing equipment.

10. WHO has developed and implemented a project in the maternity units of public hospitals in the Gaza Strip to improve the quality and safety of patient care during childbirth. The project is targeting maternity and neonatal units in seven hospitals, covering about 90% of births in the Gaza Strip. Critical changes in childbirth care routines and environment have been introduced, including promotion of natural childbirth techniques and empowerment of midwives.

11. WHO continued to monitor and provide monthly reports on the referral of patients from the Gaza Strip, and in July 2011, issued an annual report to highlight barriers to patient access in 2010. About 12 340 patients were referred by the Palestinian Ministry of Health for specialized treatment to health facilities within the West Bank, including east Jerusalem, and in Egypt, Israel and Jordan. These referrals were necessary because the Gaza Strip lacks the capacity to treat such patients. The report noted that patients can suffer protracted delays in receiving permits to access medical services, can face interrogation by Israeli security forces as an application condition, and can be denied access without explanation. The number and kind of referrals are symptomatic of the slowed development of the health-care system in the Gaza Strip due to movement restrictions of people and goods into the Gaza Strip. Among other recommendations, the report called on Israel to ensure access for patients, health professionals, medical equipment, spare parts and construction materials to facilitate health services development.

12. In order to fill the current gaps in the public health system and to strengthen policy and decision-making, the Ministry of Health, with the support of WHO, the Government of Norway, and the Norwegian Public Health Institute, have agreed to establish a Palestinian National Public Health Institute to strengthen core public health functions such as evaluation and analysis of health status, public health surveillance, quality assurance and public health research. The Institute will be an independent body providing reliable health information and advice to the Ministry of Health, other decision-makers and the general public. The two-year development phase is scheduled to begin in March 2012.

13. WHO has moved into the second phase of a programme to improve the quality of hospital services at the six specialized medical facilities in east Jerusalem, comprising the East Jerusalem Hospitals Network. The east Jerusalem hospitals serve as the main referral centres for tertiary care for Palestinians from the West Bank and the Gaza Strip. WHO is working with the hospitals to build a culture and system of patient safety and quality improvement according to the standards of the Joint Commission International in order for the hospitals to eventually achieve accreditation. WHO has also continued to monitor patient access from the West Bank and the Gaza Strip to the east Jerusalem hospitals, as well as access of ambulances, hospital employees, and medical and health students for training from the West Bank.

14. WHO is also working with the Ministry of Health on quality improvement in its service delivery system. A focal point for quality improvement and patient safety has been appointed at each of the district hospitals and the primary health-care department. A pilot assessment of the quality of services at primary health-care clinics was completed in the Ramallah governorate. In addition, the Ministry of Health has selected two governmental hospitals to implement the WHO Patient Safety Friendly Hospital Initiative.

15. WHO, with funding from the European Union, has supported the development of community-based mental health services in the West Bank and the Gaza Strip. Over the last three years, the Ministry of Health has established mental health units in the West Bank and the Gaza Strip to lead the mental health reforms. A new Strategic Mental Health Plan 2012–2014 has been developed. Other activities include support for the development of community mental health services including services provided through primary care clinics, establishment of postgraduate mental health programmes in local universities, capacity building of staff, the creation of a nongovernmental organization bringing together family associations, and public education to raise the awareness of the general public and combat stigma towards people with mental health problems. The project ended in May 2011 and a further phase of the project is in preparation.

16. WHO provided technical support to the Ministry of Health for implementation of a national strategy to prevent and manage noncommunicable diseases. A first survey in the West Bank and the Gaza Strip was conducted to obtain data on risk factors (smoking, hypertension, obesity and lack of physical activity). The first global school-based student health survey targeted school students between 13 and 15 years. Results provided information on risk factors and will be used to design interventions to address these issues. The Ministry of Health will begin to train health-care providers on the WHO package of essential interventions to integrate noncommunicable disease prevention and management at primary health-care level; WHO will support the implementation of the integrated approach and the needed changes to optimize health systems.

17. WHO also co-chairs the Working Group on Tobacco Control that supports and oversees the implementation of tobacco control activities. The political commitment of the Ministry of Health and other line ministries facilitated the establishment of an anti-smoking intersectoral committee to prepare by-laws for the existing anti-smoking law for alignment with the WHO Framework Convention on Tobacco Control. The committee has been working on the reduction of demand for tobacco; covering protection from exposure to tobacco smoke; regulation of the contents of tobacco products and of tobacco product disclosures; packaging and labelling of tobacco products; and education, communication, training and public awareness.

18. Within the “healthy cities” framework, WHO has initiated a health and environment-friendly schools programme in the cities of Ramallah and Nablus. The programme is implemented in partnership with the two municipalities, the Ministry of Health, the Ministry of Education and wide participation from public and community organizations, as well as sponsorship from the private sector. This year, 17 schools in Ramallah district are participating in the initiative.

19. In support of activities against HIV/AIDS, WHO is a subrecipient of grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria. WHO continues to act as technical adviser to the United Nations thematic group for tuberculosis in the West Bank and the Gaza Strip, and to the occupied Palestinian territory for tuberculosis and for HIV/AIDS.5WHO supported the formulation of a Palestinian strategy, treatment guidelines and training modules on tuberculosis with technical support from the Regional Office for the Eastern Mediterranean. For HIV/AIDS, WHO conducted the first biobehavioural survey among injecting drug users in east Jerusalem in 2010 to understand the epidemiological pattern of this low-prevalence setting and provided a range of capacity-building support for treatment and blood safety. A special clinic for HIV/AIDS has been established by the Ministry of Health in the Ramallah governorate integrated into primary health-care services; a technical mission from the Regional Office will monitor the patients clinically to ensure the adoption of WHO standards of treatment and care.6
ACTION BY THE HEALTH ASSEMBLY

20. The Health Assembly is invited to note the report.

ANNEXREPORT ON THE HEALTH AND ECONOMIC SITUATION IN THE OCCUPIEDPALESTINIAN TERRITORY, INCLUDING EAST JERUSALEM, AND IN THEOCCUPIED SYRIAN GOLAN

1. This report has been prepared in response to resolution WHA64. The Secretariat has conducted a review of reports available from reliable sources that address the situation in the occupied Palestinian territory. In addition, the Government of Israel, the Government of the Syrian Arab Republic and the Palestinian Authority have been asked for information on the subject.

DETERMINANTS OF HEALTH IN THE OCCUPIED PALESTINIAN TERRITORY

2. The occupied Palestinian territory ranks 114 out of 187 countries in the UNDP Human Development Index 2011.7However, unemployment rates are among the highest in the world: above 20% in the West Bank where movement is highly restricted by checkpoints, and above 35% in the Gaza Strip due primarily to closed borders. Overall unemployment in the West Bank in the first half of 2011 was 22.4% (higher among refugees at 27.4% and lower among non-refugees at 20.1%).8In the Gaza Strip, during the same period, unemployment for non-refugees dropped to 31.6% and refugee unemployment dropped to 33.8%.9However, high underemployment and stagnation in mean wages from 2003–2009 persisted,10especially in the Gaza Strip where 45.6% of household heads were working in the public sector.

3. Poverty rates decreased slightly from 2009 levels but the regional gap is widening, with poverty in the Gaza Strip double the rate of the West Bank and deep poverty in the Gaza Strip increasing: the occupied Palestinian territory poverty rate in 2010 was 25.7% (18.3% for the West Bank and 38.0% for the Gaza Strip),11but estimated at 42.5% without humanitarian assistance for households. Deep poverty increased in the Gaza Strip from 21.9% to 23%, while it eased in the West Bank, from 9.1% to 8.8%.

4. Compared to recent years, the occupied Palestinian territory showed some improvements in 2010, growing from 7.4% in 2009 to 9.3% in 2010. Growth was more pronounced in the Gaza Strip, where gross domestic product rose by 15% compared to 7.6% in the West Bank. However, this is not a sign of sustainable recovery, but of an economy operating from a low base, given the economic regression of the last decade and ongoing deindustrialization process.

5. The continuing Israeli closure policy and confiscation of Palestinian land and natural resources raise concerns about the sustainability of the growth experienced in 2010, and the development prospects of the Palestinian economy, without a vibrant private sector.12The latter will not rebound significantly while Israeli restrictions on access to natural resources and markets remain in place, and as long as investors are deterred by the increased cost of business associated with the closure regime.13

6. The blockade imposed by Israel on the Gaza Strip since June 2007 remains in effect. In June 2010, Israel announced an easing of the blockade which has resulted in an increase of imports. However, the restrictions on the movement of people, the import of basic construction materials and the export of goods remain in place, with only a very slight economic improvement seen.

7. Close to two thirds of the population in the Gaza Strip and 25% in the West Bank face food insecurity. On average, households in the Gaza Strip spend 72% of their income on food, compared to 54% in the West Bank. Over one million Palestinians remain in need of food assistance.

8. The Gaza Strip continues to have an inadequate supply of electricity, which affects service provision as well as the daily life of the population. Service providers must continue to rely on backup generators to ensure electricity provision. The cuts in electricity supply have various adverse effects, including on the water supply to households. Water quality is also an area of serious humanitarian concern in the Gaza Strip, as 90% to 95% of the water aquifer is considered unfit for human consumption due to high levels of salts and nitrates.14

9. Israel retains control of all underground and surface-water resources in the West Bank. Palestinians are only allowed to abstract 20% of the “estimated potential” of the mountain aquifer under the West Bank, while Israel abstracts the remaining 80% plus overdraws. A number of essential projects for Palestinians have been denied permits or delayed. Average Palestinian consumption of water is of 50 lpcpd, well below the 100 litres recommended by WHO, and one fourth the average Israeli daily per capita consumption from available fresh water.15

10. Around 200 000 Palestinians in the West Bank have no access to water network connections, and must depend on expensive tankered water distributed to often hard-to-reach “filling points”. Those with network connections often have their pipes run dry, especially during the summer months, when Israel rations water to Palestinian communities to only a few days per week, while settlements have uninterrupted access. Restrictions on access to water increase the risk of displacement of Palestinians from certain areas. Settlers often vandalize Palestinian water infrastructure, contaminating wells and springs as well as destroying infrastructure and livelihoods. Raw sewage from settlements often flows through the West Bank valleys and constitutes a public health and environmental risk.

ACCESS TO HEALTH CARE

11. The occupied Palestinian territory has a relatively well-developed health system, and reaches most areas in the territory. However, the functioning and development of the system have been hindered by restrictions on importation of medical supplies, equipment and spare parts; limitations on movement of patients and health staff, insecurity and the permit regime have hampered both the access of Palestinians to health services as well as the professional development of staff.

12. The Ministry of Health, UNRWA, nongovernmental organizations and private, commercial organizations constitute the four main health providers of health services. The Ministry of Health runs 59 primary health-care centres in the Gaza Strip and 394 in the West Bank. UNRWA operates 18 primary health-care centres in eight refugee camps in the Gaza Strip and 41 centres in the West Bank. The nongovernmental organization sector manage 194 primary health-care centres and general clinics (57 in the Gaza Strip and 137 in the West Bank).16

13. There are 76 hospitals in the occupied Palestinian territory (51 in the West Bank, 25 in the Gaza Strip), with a total of 5108 beds in hospitals (including government, nonprofit and private hospitals). Almost three quarters of them are general beds, 16.0% specialized beds, 3.3% beds for rehabilitation and 6.18% maternity beds. Overall, there are 12.6 beds per 10 000 population (12.2 beds in the West Bank and 13.3 beds in the Gaza Strip).16

14. The Ministry of Health, with the support of donors, has continued to develop the scope and range of public health services in the West Bank. The hospital sector in particular has benefited from significant investment in infrastructure and equipment with several hospitals being rehabilitated and services developed. The Ministry of Health has also sought to strengthen its institutional and governance capacity, not least by further efforts to improve the planning process. However, the Palestinian health-care system continues to face many challenges, including restriction of movement and access to health services. Access to east Jerusalem, where the main tertiary health services are provided, is subject to special permits. Administrative restrictions also have an impact on the provision of health care in rural areas classified as “Area C” under the Oslo Accords.

15. While the hospitals and primary care clinics in the Gaza Strip continue to function, they face many challenges in providing an adequate and safe quality of care, including unstable power supply and shortages: 32% of essential drugs and 22% of essential medical consumables were lacking at the level of the Central Drug Store in 2011.17The shortages are mainly a result of the political divisions between the de facto authorities in the Gaza Strip and the Palestinian Authority in the West Bank. 16. A total of 7321 patients from the Gaza Strip were referred by the Ministry of Health for medical treatment outside Palestine in 2011, to Egypt, Israel and Jordan. In 2011, 10% of patients applying for permits to leave the Gaza Strip for medical treatment were denied permits, or were delayed, missing their treatment date; 197 patients were called for interrogation after applying for a permit.18

HEALTH STATUS

17. Overall life expectancy is 73.6 years for females and 70.8 years for males. The population of the occupied Palestinian territory is increasing at an annual rate of 2.9% (i.e. 2.6% in the West Bank and 3.3% in the Gaza Strip). The crude birth rate declined over the last decade from 42.7 in 1997 to 29.6 in 2008.19In the first half of 2011, 98.35% of births took place in health facilities (64.84% of births in Ministry of Health hospitals).

18. The four leading causes of death in the occupied Palestinian territory in 2010 were cardiovascular diseases, cerebrovascular diseases, cancer (led by lung, colorectal and breast cancer) and respiratory system diseases. However, in mid-2011, the fourth leading cause was registered as conditions in the perinatal period.20

19. The infant mortality rate is showing an overall decline over the past decade from 35 per 1000 in 1999 to 25 per 1000 in 2009.21The main causes of death among infants are pneumonia and other respiratory disorders (34.5%), congenital malformations (16.3%) followed by prematurity and low birth weight (13.4%).22

20. Infant mortality rates in the occupied Palestinian territory have decreased slowly over the last two decades, but also show a growing gap between the West Bank and the Gaza Strip, indicating that health determinants and health care are not sufficiently developed to achieve the expected progress in reduction of child mortality and improvement of maternal health. The infant mortality rate declined from 25.5 per 1000 live births in 2000 to 20.6 per 1000 live births in 2010 (18.8 in the West Bank and 23.0 in the Gaza Strip). Similarly, the under-five mortality rate declined from 28.7 per 1000 live births in 2000 to 25.1 per 1000 live births in 2010 but with a wide gap between regions (22.1 in the West Bank and 29.2 in the Gaza Strip). Conditions originating in the perinatal period are the leading cause of under-five mortality in the West Bank, at 50.8%.23The infant and child mortality rates could be substantially reduced by efforts towards improving the quality of perinatal care.

21. Maternal mortality was 32 per 100 000 live births in 2010 in the West Bank and 29 per 100 000 live births in the Gaza Strip – a ratio comparable to neighbouring Arab countries, although it is likely to be underestimated.24

22. In the West Bank, about 50% of maternal deaths occurred in private hospitals. Among the 53 reviewed maternal deaths in the West Bank and the Gaza Strip, 17 (32%) occurred intra-partum or during the first 24 hours post-partum. At least 57% of deaths in the West Bank were preventable. The risk of death associated with caesarean sections was found to be six times higher than the risk associated with normal delivery.25The caesarean section rate in the West Bank is high and has increased from less than 10% of total deliveries in 2000, to an average of 20% in mid-2011 in Ministry of Health hospitals and more than 30% in some hospitals, twice the maximum rate recommended by WHO.26

23. Anaemia and micronutrient deficiencies are further areas of concern. It is estimated that 50% of infants and young children under two years of age in the West Bank and the Gaza Strip suffer from iron deficiency anaemia, which is associated with inappropriate infant and young child feeding practices and limited access to, or compliance with, micronutrient supplementation. For malnutrition in children under five years, stunting (chronic malnutrition) is not improving and may be deteriorating. A high prevalence of anaemia is revealed among women visiting antenatal services (39.1% of pregnant women in the Gaza Strip and 15.4% in the West Bank).

24. Children have presented with a higher level of symptoms of emotional stress and indications of emotional stress present in 14.2% of kindergarten-aged children. In the first half of 2011, there were 332 cases of children presenting with conflict-related psychosocial symptoms; 20% of children suffer from familial violence.27

SITUATION IN THE OCCUPIED SYRIAN GOLAN

25. WHO does not have access to the occupied Syrian Golan. A report by the Ministry of Health of the Syrian Arab Republic on the health conditions in the occupied Syrian Golan is contained in document A65/INF.DOC./2. A report provided by the Ministry of Health of Israel is provided in document A65/INF.DOC./3.